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                                                                                                                                                                                VOID                       OMB No. 1545-2252
Form 1095-B                                                                    Health Coverage
Department of the Treasury                                    ▶ Do not attach to your tax return. Keep for your records.                                                        CORRECTED                  2021
Internal Revenue Service                             ▶ Go to www.irs.gov/Form1095B for instructions and the latest information.
Part I       Responsible Individual
1    Name of responsible individual–First name, middle name, last name                                                            2   Social security number (SSN) or other TIN  3   Date of birth (if SSN or other TIN is not available)

4   Street address (including apartment no.)                               5    City or town                                      6    State or province                         7    Country and ZIP or foreign postal code

                                                                                                                                  9    Reserved
8   Enter letter identifying Origin of the Health Coverage (see instructions for codes):  .         .  .    ▶
Part II      Information About Certain Employer-Sponsored Coverage (see instructions)
10    Employer name                                                                                                                                                             11    Employer identification number (EIN)

12   Street address (including room or suite no.)                          13    City or town                                     14    State or province                       15    Country and ZIP or foreign postal code

Part III     Issuer or Other Coverage Provider (see instructions)
16    Name                                                                                                                        17    Employer identification number (EIN)    18    Contact telephone number

19   Street address (including room or suite no.)                          20    City or town                                     21    State or province                       22    Country and ZIP or foreign postal code

Part IV      Covered Individuals (Enter the information for each covered individual.)
         (a) Name of covered      individual(s)           (b) SSN or other TIN      (c) DOB (if SSN or other     (d) Covered                                       (e)     Months     of coverage                                
       First name, middle initial, last name                                     TIN is not available) all 12 months
                                                                                                                             Jan        Feb    Mar        Apr May            Jun      Jul Aug         Sep  Oct       Nov    Dec

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For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                                                                   Cat. No. 60704B                                                Form 1095-B (2021)

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Form 1095-B (2021)                                                                                                                                   Page 2 

Instructions for Recipient                                                              If you or another family member received health insurance 
                                                                                TIP     coverage through a Health Insurance Marketplace (also known as 
This Form 1095-B provides information about the individuals in your tax 
                                                                                        an Exchange), that coverage will generally be reported on a  
family (yourself, spouse, and dependents) who had certain health coverage 
(referred to as “minimum essential coverage”) for some or all months during     Form 1095-A rather than a Form 1095-B. If you or another family member 
the year. Minimum essential coverage includes government-sponsored              received employer-sponsored coverage, that coverage may be reported on a 
programs, eligible employer-sponsored plans, individual market plans,           Form 1095-C (Part III) rather than a Form 1095-B. For more information, see 
and other coverage the Department of Health and Human Services                  www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-Health-
designates as minimum essential coverage.                                       Care-Information-Forms-for-Individuals.
Before 2019, individuals who did not have minimum essential coverage            Line 9. Reserved.
and did not qualify for an exemption from this requirement could be liable for 
the individual shared responsibility payment. Beginning in 2019, individuals    Part II. Information About Certain Employer-Sponsored Coverage, lines 
will not be responsible for the individual shared responsibility payment        10–15. If you had employer-sponsored health coverage, this part may 
because the payment amount is reduced to $0. However, if individuals in         provide information about the employer sponsoring the coverage. This part 
your tax family are eligible for certain types of minimum essential coverage,   may show only the last four digits of the employer’s EIN. This part may also 
you may not be eligible for the premium tax credit. For more information on     be left blank, even if you had employer-sponsored health coverage. If this 
the premium tax credit, see Pub. 974, Premium Tax Credit (PTC).                 part is blank, you do not need to fill in the information or return it to your 
                                                                                employer or other coverage provider.
        Providers of minimum essential coverage are required to furnish 
                                                                                Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports 
TIP     only one Form 1095-B for all individuals whose coverage is              information about the coverage provider (insurance company, employer 
        reported on that form. As the recipient of this Form 1095-B, you        providing self-insured coverage, government agency sponsoring coverage 
should provide a copy to other individuals covered under the policy if they     under a government program such as Medicaid or Medicare, or other 
request it for their records.                                                   coverage sponsor). Line 18 reports a telephone number for the coverage 
                                                                                provider that you can call if you have questions about the information 
Additional information. For additional information about the tax provisions 
                                                                                reported on the form.
of the Affordable Care Act (ACA), including the individual shared 
responsibility provisions, and the premium tax credit, see www.irs.gov/ACA      Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN 
or call the IRS Healthcare Hotline for ACA questions (800-919-0452).            or other TIN, and coverage information for each covered individual. A date of 
                                                                                birth will be entered in column (c) only if the SSN or other TIN is not entered 
Part I. Responsible Individual, lines 1–9. Part I reports information about 
                                                                                in column (b). Column (d) will be checked if the individual was covered for at 
you and the coverage.
                                                                                least 1 day in every month of the year. For individuals who were covered for 
Lines 2 and 3. Line 2 reports your social security number (SSN) or other        some but not all months, information will be entered in column (e) indicating 
taxpayer identification number (TIN), if applicable. For your protection, this  the months for which these individuals were covered. If there are more than 
form may show only the last four digits. However, the coverage provider is      six covered individuals, see Part IV, Continuation Sheet(s), for information 
required to report your complete SSN or other TIN, if applicable, to the IRS.   about the additional covered individuals.
Your date of birth will be entered on line 3 only if line 2 is blank.
Line 8. This is the code for the type of coverage in which you or other 
covered individuals were enrolled. Only one letter will be entered on this line.
A. Small Business Health Options Program (SHOP)
B. Employer-sponsored coverage
C. Government-sponsored program
D. Individual market insurance
E . Multiemployer plan
F . Other designated minimum essential coverage
G . Individual coverage health reimbursement arrangement (HRA)

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Form 1095-B (2021)                                                                                                                                                                                                                 Page 3 
Name of responsible individual–First name, middle name, last name                                                                Social security number (SSN) or other TIN     Date of birth (if SSN or other TIN is not available)

Part IV   Covered Individuals — Continuation Sheet
        (a) Name of covered      individual(s)           (b) SSN or other TIN      (c) DOB (if SSN or other     (d) Covered                          (e)     Months     of coverage                             
       First name, middle initial, last name                                  TIN is not available)   all 12 months
                                                                                                                            Jan  Feb  Mar  Apr  May                        Jun Jul Aug  Sep  Oct       Nov                         Dec

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                                                                                                                                                                                                  Form 1095-B (2021)